Frequently Asked Questions About Complex PTSD

What may I have been misdiagnosed with?

Renowned traumatologist, John Briere, is said to have quipped that if Complex PTSD were ever given its due – that is, if the role of dysfunctional parenting in adult psychological disorders was ever fully recognized, the DSM (The Diagnostic and Statistical Manual of Mental Disorders used by all mental health professionals) would shrink to the size of a thin pamphlet. It currently resembles a large dictionary. In my experience, many clients with Complex PTSD have been misdiagnosed with various anxiety and depressive disorders, as well as bipolar, narcissistic, codependent and borderline disorders. Further confusion arises in the case of ADHD (Attention Deficit Hyperactive Disorder), as well as obsessive/compulsive disorder, which is sometimes more accurately described  as an excessive, fixated flight response to trauma. This is also true of ADD (Attention Deficit Disorder) and some dissociative disorders which are similarly excessive, fixated freeze responses to trauma. (See my article “A Trauma Typology”.)

This is not to say that those so diagnosed do not have issues that are similar and correlative with said disorders, but that these labels are incomplete and unnecessarily shaming descriptions of what the client is afflicted with. Calling complex PTSD “panic disorder” is like calling food allergies chronically itchy eyes; over-focusing treatment on the symptoms of panic in the former case and eye health in the latter does little to get at root causes. Feelings of panic or itchiness in the eyes can be masked with medication, but all the other associated problems that cause these symptoms will remain untreated. Moreover most of the diagnoses mentioned above imply deep innate characterological defects rather than the learned maladaptations to stress that children of trauma are forced to make– adaptations, once again that were learned and can therefore usually be extinguished and replaced with more functional adaptations to stress.

In this vein, I believe that many substance and process addictions also begin as misguided, maladaptations to parental abuse and abandonment – early adaptations that are attempts to soothe and distract from the mental and emotional pain of complex PTSD.

What are the signs that I’m recovering?

Effective recovery work leads to an ongoing gradual reduction of emotional flashbacks. Over time we become more and more proficient at managing them and alleviating unnecessary states of activation; this in turn results in flashbacks occurring less often, less enduringly and less intensely.

Another key sign of recovering is that the critic begins to shrink and lose its dominance of the psyche. As it shrinks, the user-friendly ego has room to grow and to develop the kind of mindfulness that more readily recognizes when the critic has taken over, which in turn allows us to more readily disidentify form or fight against its perfectionistic and drasticizing processes.

Another sign of recovering occurs as a gradual increase in our ability to relax  - to resist overreacting from a triggered position, i.e., from an inappropriate fight, flight, freeze or fawn response; (See my article: “A Trauma Typology”). Moreover, there is an increase in our ability to use our fight, flight, freeze and fawn instincts in healthy non-self-destructive ways, so that we only fight back when under real attack, only flee when odds are insurmountable, only freeze when we need to go into acute observer mode, only fawn when it is appropriate to be self-sacrificing. Another way of describing this is that we have good balance between the polar opposites of fight and flight, i.e., we can vacillate healthily between asserting our own needs and compromisingly acquiescing to the needs of others. Moreover we can balance the polar opposites of flight and freeze, which in their moderate manifestations looks like a balance between doing and being, between sympathetic and parasympathetic nervous system arousal, between left and right brain processing.

Advanced recovery correlates with letting go the salvation fantasy that we will never have another flashback, and moving into an attitude of accepting the inevitability of a modicum of flashbacks. This attitude then allows us to easily recognize and quickly respond to them from a position of self-compassion, self-soothing and self-protection.

How Did I Get Complex PTSD?

The genesis of complex PTSD is most often associated with extended periods of ongoing physical and/or sexual abuse in childhood. My observations however convince me that ongoing extremes of verbal and/or emotional abuse also cause it. Moreover as an upcoming article on my website will explicate, long-term childhood emotional neglect alone can also create complex PTSD and a propensity to emotional flashbacks.

This can perhaps best be understood by noting the conditions that prevailed as the human brain evolved during hunter-gatherer times, which represents 99.8% of our time on this planet. Children’s vulnerability to predators caused them to evolve an intense, instinctual fear response to being left alone without protection. Fear became the child’s hard-wired response to separation from a protective adult, and linked automatically to the fight response so that the infant and toddler would automatically cry angrily for attention, help, cessation of abandonment - even at the briefest loss of contact with parental figures. Beasts of prey only needed seconds to snatch away the unprotected child.

In present time dysfunctional families, many parents disdain children for needing so much attention from them, and react contemptuously to a baby or toddler’s plaintive call for connection and attachment. Contempt can sometimes be more traumatizing than physical abuse. It is a toxic cocktail of verbal and emotional abuse, a deadly amalgam of rage and disgust. Rage creates fear and disgust creates shame in the child in a way that soon teaches her to refrain from crying out, from ever asking for attention, and before long from seeking any kind of help or connection at all. Particularly abusive parents deepen the abandonment trauma by linking corporal punishment with contempt.

Moreover, as stated above, complex PTSD can also be caused by emotional neglect alone; (emotional neglect also typically occurs in most situations of prolonged contempt and physical abuse). Parents who systematically ignore or turn their backs on a child’s calls for attention, connection or help, abandon their child to unmanageable amounts of fear which over time devolve into the child giving up and succumbing to depressed, death-like feelings of helplessness and hopelessness. These types of rejection simultaneously magnify the child’s fear, and eventually add a veneer of shame to it. Over time this fear and shame cancerously begets a toxic inner critic that increasingly dominates the psyche with programs of endangerment and self-disgust (perfectionism), until a full blown case of PTSD is established. (See my articles on The Inner and Outer Critic).

Moreover, to the duration and degree that emotional abandonment takes place and to the degree that there is no alternative adult (relative, older sibling, neighbor, teacher) to turn to for comfort and protection, to that degree does the PTSD set in, and to that degree can a myriad of triggers (external or internal) activate the individual into flashing back into the painful emotional and toxic cognitive conditions of childhood. This is especially true when the abandonment occurs 24/7, 365 days a year for the first few years.

How do I know I am in a Flashback?

We can often find ourselves in a flashback without ever having seen the “flash”. There are a variety of clues that we can learn to identify as signs that we are caught in a flashback. This is essential to recovery, as naming our experience “flashback” (step#1 in flashback management) often immediately brings some relief, and more importantly point us in the direction of working the other 12 steps of flashback management (listed on the flashback management page of this website).

One common clue that we are in a flashback occurs when we notice that we feel small, helpless, hopeless and so ashamed that we are loath to go out or show our face anywhere.

Another common clue that we are flashing back is an increase in the virulence of the inner or outer critic. This typically looks like increased drasticizing and catastrophizing, as well as excessive self-criticism or judgementalness of others. A very common example of this is lapsing into extremely polarized, all-or-none thinking – and most especially into only noticing what is wrong with yourself and/or others. On a personal level, I have learned over the years that when I am feeling especially critical of others, it usually means that I am feeling bad and have flashed back to being around my mother who hated any dip in my mood or energy level lest I be less useful and entertaining to her. During such flashbacks then, I am self-protectively over-noticing other’s faults so I can justify avoiding them and the danger and shame of being seen in a state of not being shiny enough. See my articles on “Shrinking the Critic” for more info on how to recognize the various critic attacks that accompany as well as initiate flashbacks.

Another clue about flashbacks is seen in increased activation of the fight, flight, freeze or fawn responses (see my article on “A Trauma Typology”). Here are some examples of this. Many childhood trauma survivors learned early in life to manage and self-medicate the painful feelings of flashbacks with distracting activities and self-medicating substances - flight and freeze responses, respectively. Over time flight and freeze responses can become habitual. Flight types can devolve into distracting process addictions, and freeze types into “tuning out” substance addictions. The former can morph into workaholism, busyholism, consumerism, or sex &love addiction, and the latter into drinking, drugging, TV entrancement and compulsive eating (especially mood-altering junk foods that contain high quantities of salt, sugar and fat). Addiction for many survivors is a matter of degree, and an especially strong urge to use more substance or process than normal is a powerful clue that one is in a flashback. With practice, mindfully noticing a sudden upsurge in craving can be interpreted as the need to invoke the 13 steps of healthy flashback management.

Another clue that we are in a flashback occurs when we notice that our emotional reactions are out of proportion to what has triggered them, e.g., when a minor, present time upset feels like an emergency or when a minor unfairness feels like a travesty of justice; e.g., a spilled glass of water triggers an incessant diatribe of self-hate, or someone else’s relatively harmless, un-signaled lane change triggers us into rage. If we are not mindful at such times, we can either inappropriately act these feelings out against the relatively innocent other, or we can let them morph into shame and act them in against ourselves in self-disgust or self-hatred. If on the other hand we mindfully recognize them as flashbacks to the way we felt about the real emergencies and injustices of parental abuse and abandonment, we can be empowered not only to invoke healthy flashback management techniques, but also to harvest the experience as an opportunity to validate the awfulness of our childhood plight. When we do the latter, we can assign and direct our anger into a self-protective protest about the unfair past, and our tears into self-compassionate crying for the plight of the child we were. Finally, it cannot be stressed enough that it takes a great deal of practicing both of these responses to heal the developmental arrest of being blocked from our all important instincts of self-protection and self-compassion. 

What is a trigger?

A trigger is an external or internal stimulus that activates us into an emotional flashback. This often occurs on a subliminal level outside the boundaries of normal consciousness, and is why recognizing flashbacks is both difficult but crucially important. External triggers are people, places, things, events, facial expressions, styles of communication, etc., that remind us of our original abuse or abandonment in a way that launches us into reliving the painful feelings of those times; e.g., revisiting your parents or childhood home, seeing someone who resembles your childhood abuser, experiencing the anniversary of an especially traumatic event, or hearing someone use a parent’s shaming turn of phrase. When trauma has been severe or we are in an especially depleted state, resemblances can even be scant – perhaps all unknown men or authority figures trigger fear, or anyone noticing or looking at us triggers toxic shame. I was once intensely triggered by a squirrel staring at me!

Internal triggers are usually initiated by the critic and involve thoughts and visualizations about endangerment or the need for perfection; e.g., visualizing someone being abusive, or worrying about not being perfect in executing some current or upcoming task. As recovery progresses, many survivors are shocked to discover that the majority of their flashbacks are triggered internally by the various internal programs of the inner critic.

With ongoing recovery, we can become more cognizant of our triggers, and work more quickly to work through incidents of being triggered into a flashback, or even  recognize potentially triggering situations and prophylactically invoke the flashback management steps before we get activated.

What is the Abandonment Depression?
The Abandonment Melange?

The Abandonment Depression is the complex painful childhood experience that is reconstituted in an emotional flashback. It is a return to the sense of overwhelm, hopelessness and helplessness that afflicts the abused and /or emotionally abandoned child. At the core of the abandonment depression is the abandonment melange – the terrible emotional mix of fear and shame that coalesces around the deathlike feelings of depression that afflict an abandoned child. Surrounding the abandonment melange of the flashback are perfectionistic and endangerment cognitions and visualizations of the toxic inner and outer critic (See my articles on the critic), and at the surface is the self-destructive enactments of the fight, flight, freeze or fawn responses (See “A Trauma Typology”).

In a typical flashback, an individual is recapitulated into the original experience of abandonment. Fear is immediately triggered and soon produces shameful feelings of self-hate. This self-hate is a self-rejection that mimics parental rejection and that is equivalent to self-abandonment. Self-abandonment in turn deepens the abandonment depression and creates an even more fearful state, which in turn generates even more shame about the fear, which triggers increasingly depressing self-abandonment. This process then becomes a self-perpetuating, perpetual motion cycle that can spiral around and around in a despairingly painful descent that at its worst culminates in feelings of panic and suicidal ideation. During particularly extreme flashbacks, more than a few of my clients have uttered things that sound like this: “Life is so hopelessly depressing, I might as well be dead. Take me now God, why don’t you!” (See Managing The Abandonment Depression” for practical guidance on how to respond therapeutically to the abandonment melange.)

Why does it take so long to actually get that you’re recovering?

Because of the all-or-none thinking that typically accompanies Complex PTSD, survivors in the early stages of recovery often fail to notice or validate their own actual progress. Inner critic thought processes discount signs of progress whenever a new flashback occurs, no matter how much less intense it is than before. Every recurrence of feeling shame, fear or depression is interpreted as proof that nothing’s changed even when there are increasing periods of not being overactivated. The critic’s black-and-white assessment is “Either I’m cured or I’m still hopelessly defective”, and once we identify with the critic’s pronouncement of defectiveness, we are off and spiraling downward into a full fledged flashback, and captured once again in the ice veneer of toxic shame that freezes us helplessly and hopelessly in our pain.

It is exceedingly difficult to accept the proposition – the fact – that recovery is never complete. And although we can expect our flashbacks to markedly decrease over time, how hard it is to let go of the salvation fantasy that we will one day be forever free of them. Yet if we do not disidentify from this expectation, we will remain extremely susceptible to blaming and shaming ourselves every time we have a flashback. Understanding and accepting this is so crucial because recovery typically progresses in a process that is two steps forward and one backwards, with the unfortunate subjective experience that at times that one step backwards feels for all the world like six. This is especially true because of the interminability feeling of flashbacks – the recreation of the feeling/being state of the child who had no capacity or resources to imagine a future that would be significantly different than the seemingly everlasting present of being so abandoned.

So how can we come to bear the knowledge that our awful childhoods have created some permanent damage, that we have a condition that is somewhat analagous to diabetes – a condition that will need management throughout our lives. It’s a piece of bad news that’s tremendously unpalatable, but the good news, as with diabetes, is that as we become more skilled at flashback management, fully rich and rewarding lives become increasingly possible. Even better is the news that Complex PTSD, when efficiently managed, eventually bestows some gifts and silver linings unavailable to those less traumatized. We live in an emotionally and relationally impoverished culture, and those who work deeply to assuage their wounds are often rewarded with emotional intelligence far beyond the norm, and a capacity for intimacy that is rarely seen in the general populace. This multidimensional intimacy is that which comes when two people mutually communicate about all aspects of their experience, happy and sad, loving and angry, enthused and disappointed, and are thus able to be in authentic supportive connection in all states of human being. 

Healing from PTSD is also a long, gradual process because recovering our developmentally arrested instincts of full self-expression requires practicing new self-championing behaviors that trigger flashbacks to times when we were punished or abandoned for acting in our own self-interest. Self-championing was punished like a capital crime in many dysfunctional families. The flashback pain that this kind of practicing triggers can feel so acute that it masks the gradual relief and reduction of the chronic pain of remaining invisible. The pain of flashbacks induced by practicing self-expressive behavior that was punishable in the childhood family is a bit like going to the dentist for a toothache. Unless we accept the acute pain of the dentist’s therapeutic procedure, we will suffer chronic dental discomfit indefinitely. 

Recovering from overwhelmingly painful childhoods is hard because we can’t help wanting to avoid any kind of pain at all – whether it is the normal existential growing pain of learning new difficult things, or the flashback-inducing pain of choosing to cultivate the developmentally delayed instincts of self-compassion and self-protection. These quests sometimes become more embraceable to me when I remember the poet’s words: “He not busy being born is busy dieing”.  And as black and white as this aphorism might strike those of you who have significantly shrunk your critic, some of the latest research in neuroscience suggests that we actually need a modicum of stress in our life – which is now called optimal stress. This stress is the balanced, moderate amount of stress that appears to be necessary to grow the new neurons and neuronal connections that correlate with keeping the brain healthy. Research shows that just as too much stress creates a biochemical condition that kills neurons in the brain, too little leads to the atrophy, death and lack of replacement of old neurons. This is why life long learning is widely recognized as one of the key practices necessary to avoid Alzheimer’s disease.

Why do you specialize in Complex PTSD?

There’s an old adage: “Teach what you know.” I know about trauma because I survived childhood in the war zone of a severely dysfunctional family in NYC in the 1950’s. The frontline was definitely in my house, but there were many traumatizing skirmishes on the streets and in the Catholic school where I was held captive by mean, red-faced, yardstick-wielding women in penguin suits. I escaped my family into the Viet Nam era army, and although I only went there briefly, my year of training to be a combat platoon leader helps me see the parallels between war-induced trauma and dysfunctional family begotten trauma.

By the time I was 25, I had survived a decade of high risk activity peppered with what now look like unconscious suicide attempts, before I finally realized that I was seriously hurting. I have spent four decades personally exploring varied psychological and spiritual approaches to healing my trauma, and the personal gains I have made coupled with the healing I have witnessed in my clients and students over the last 30 years has given me, I believe, a unique perspective and set of tools to share with my fellow PTSD sufferers. I have pieced together a map and an eclectic blend of perspectives and techniques that can significantly ameliorate Complex PTSD. My approach helps manage the complex symptomology of emotional flashbacks and provides encouragement to endure the long, arduous, Sisyphean climb out of being continuously triggered into unresolved childhood abandonment pain. (For more on the map, see “Managing the Abandonment Depression” on this website.)

In my ongoing work with PTSD recovery, I repeatedly experience much gratitude toward the many clients who’s authenticity and vulnerability while in flashback help me further illuminate the map; and I am further grateful for how they validate to my inner child that: “Yes it’s true, there really are parents who were so mean and/or so out to lunch, that they installed in us this painful, stubborn syndrome of Complex PTSD”.